US9241784B2 - Soft tissue reconstruction - Google Patents

Abstract

Methods and instruments for reconstructing soft tissues of a skeletal joint such as for example of the foot or hand are presented.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of U.S. patent application Ser. No. 13/527,648, filed Jun. 20, 2012, which claims the benefit of U.S. Provisional Application No. 61/568,137, filed Dec. 7, 2011, U.S. Provisional Application No. 61/505,992, filed Jul. 8, 2011, U.S. Provisional Application No. 61/506,000, filed Jul. 8, 2011, U.S. Provisional Application No. 61/506,004, filed Jul. 8, 2011. All of the cross-referenced non-provisional and provisional applications are herein incorporated by reference.

FIELD OF THE INVENTION

The invention relates to methods and instruments for reconstructing soft tissues of a skeletal joint such as for example of the foot or hand.

BACKGROUND

Various conditions may affect skeletal joints such as the elongation, shortening, or rupture of soft tissues associated with the joint. Joint function may be restored by reconstruction of the soft tissues associated with the joint.

SUMMARY

The present invention provides methods for reconstructing soft tissues associated with joints.

In one aspect of the invention, a method of reconstructing soft tissue adjacent a metapodial phalangeal joint of a human extremity includes forming a metapodial bone tunnel in the metapodial bone; forming a phalangeal bone tunnel in the proximal phalanx; placing a graft between the metapodial and phalangeal bone tunnels; and securing the graft.

In another aspect of the invention, a method of reconstructing soft tissue adjacent a metapodial phalangeal joint includes positioning a drill guide adjacent the joint; engaging a first reference portion of the drill guide with a first anatomic landmark; aligning a first guiding portion of the drill guide in alignment with a medial-dorsal aspect of the metapodial bone; aligning a second guiding portion of the drill guide in alignment with a lateral-dorsal aspect of the metapodial bone; guiding a cutter with the first guiding portion to form a first tunnel into the metapodial bone; and guiding a cutter with the second guiding portion to form a second tunnel into the metapodial bone intersecting the first tunnel.

In another aspect of the invention, a method of reconstructing soft tissue adjacent a metapodial phalangeal joint includes positioning a drill guide adjacent the joint; engaging a first reference portion of the drill guide with a first anatomic landmark; aligning a guiding portion of the drill guide in alignment with the proximal phalanx; and guiding a cutter with the guiding portion to form the phalangeal tunnel.

In another aspect of the invention, a method of reconstructing an accessory collateral ligament adjacent a metatarsophalangeal joint of a human foot includes positioning a drill guide adjacent the joint; aligning a first guiding portion of the drill guide in alignment with the anatomic attachment of an accessory collateral ligament on the metatarsus; aligning a second guiding portion of the drill guide in alignment with the proximal phalanx; guiding a cutter with the first guiding portion to form tunnel in the metatarsus; guiding a cutter with the second guiding portion to form a tunnel in the proximal phalanx; placing graft material at least partially into the first tunnel; placing graft material at least partially into the phalangeal tunnel; and securing the graft material in the tunnels.

In another aspect of the invention, a method of reconstructing an accessory collateral ligament adjacent a metatarsophalangeal joint of a human foot includes positioning a drill guide adjacent the joint; aligning a guiding portion of the drill guide in alignment with the anatomic attachment of an accessory collateral ligament on the metatarsus; guiding a cutter with the guiding portion to form a tunnel in the metatarsus; placing graft material such that it passes from the tunnel around a portion of the intermetatarsal ligament and back to the tunnel; and securing the graft material relative to the tunnel.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the present invention will be discussed with reference to the appended drawings. These drawings depict only illustrative examples of the invention and are not to be considered limiting of its scope.

FIG. 1 is side elevation view of the human foot illustrating anatomic reference planes;

FIG. 2 is a dorsal view of the metatarsus and proximal phalanx of the right second metatarsophalangeal joint of the human foot;

FIG. 3 is a medial view of the bones ofFIG. 2;

FIG. 4 is a lateral view of the bones ofFIG. 2;

FIG. 5 is a perspective view of an illustrative example of a guide according to the present invention;

FIG. 6 is a top plan view of the guide ofFIG. 5;

FIG. 7 is an exploded perspective view of the guide ofFIG. 5;

FIG. 8 is an exploded top plan view of the guide ofFIG. 5;

FIG. 9 is a perspective view of the guide ofFIG. 5 showing a position of the guide;

FIG. 10 is a perspective view of the guide ofFIG. 5 showing a position of the guide;

FIG. 11 is a perspective view of the guide ofFIG. 5 showing a position of the guide;

FIG. 12 is a perspective view of the guide ofFIG. 5 showing a position of the guide;

FIG. 13 is a perspective view of the guide ofFIG. 5 showing a position of the guide;

FIG. 14 is a perspective view of a tube useable with the guide ofFIG. 5;

FIG. 15 is a side elevation view of the tube ofFIG. 14;

FIG. 16 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 17 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 18 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 19 is a top plan view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 20 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 21 is a top plan view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 22 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 23 is a top plan view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 24 is a side elevation view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 25 is a top plan view of the guide ofFIG. 5 in use with an MTP joint;

FIG. 26 is a perspective view of an illustrative example of a guide according to the present invention.

FIGS. 27-35 illustrate soft tissue reconstruction of the MTP joint of the human foot using tunnels formed with a guide according to the present invention;

FIG. 36 is a perspective view of an illustrative example of a guide according to the present invention;

FIG. 37 is front elevation view of the guide ofFIG. 36;

FIG. 38 is a side elevation view of the guide ofFIG. 36;

FIG. 39 is a top plan view of the guide ofFIG. 36 taken along line39-39 ofFIG. 38;

FIG. 40 is a top plan view of the guide ofFIG. 36 in use with an MTP joint;

FIG. 41 is a side elevation view of the guide ofFIG. 36 in use with an MTP joint;

FIG. 42 illustrates soft tissue reconstruction of the MTP joint of the human foot using tunnels formed with a guide according to the present invention;

FIG. 43 is a side elevation view of an illustrative example of a guide according to the present invention;

FIG. 44 illustrates soft tissue reconstruction of the MTP joint of the human foot using tunnels formed with a guide according to the present invention; and

FIG. 45 illustrates soft tissue reconstruction of the MTP joint of the human foot using tunnels formed with a guide according to the present invention.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

The following illustrative examples illustrate instruments and techniques for treating skeletal joints. Instruments and techniques according to the present invention may be used in conjunction with any skeletal joint but the illustrative examples are shown in a size and form most suitable for the joints of the hand and foot. The hand and foot have a similar structure. Each has a volar aspect. In the hand the volar, or palmar, aspect includes the palm of the hand and is the gripping side of the hand. In the foot the volar, or plantar, aspect is the sole of the foot and is the ground contacting surface during normal walking. Both the hand and foot have a dorsal aspect opposite the volar aspect. Both the hand and foot include long bones referred to as metapodial bones. In the hand, the metapodial bones may also be referred to as metacarpal bones. In the foot, the metapodial bones may also be referred to as metatarsal bones. Both the hand and foot include a plurality of phalanges that are the bones of the digits, i.e. the fingers and toes. In both the hand and foot, each of the most proximal phalanges forms a joint with a corresponding metapodial bone. This joint includes a volar plate or band of connective tissue on the volar side of the joint. The joint also includes collateral ligaments on the medial and lateral sides of the joint. A transverse ligament, or intermetapodial ligament, connects the heads of the metapodial bones. In the hand the joint is typically referred to as the metacarpophalangeal joint having a palmar plate on the palmar side, collateral ligaments medially and laterally, and a transverse ligament connecting the metacarpals. In the foot the joint is typically referred to as the metatarsophalangeal joint having a plantar plate on the plantar side, collateral ligaments medially and laterally including proper collateral ligaments and accessory collateral ligaments, and a transverse ligament also known as the transverse metatarsal ligament or intermetatarsal ligament.

For convenience, the illustrative examples depict the use of instruments and techniques according to the present invention on metatarsophalangeal (MTP) joints of the human foot. The illustrative instruments and techniques are also suitable for use on metacarpophalangeal (MCP) joints of the human hand and other surgical sites. To better orient the reader, the MTP joint and basic anatomic references are explained in more detail below.

FIG. 1 illustrates the anatomic planes of the foot that are used for reference in this application. Thecoronal plane10 extends from themedial aspect12 to the lateral aspect of the foot and from dorsal14 to plantar16 and divides the foot between the toes and heel. Thesagittal plane18 extends anterior20 toposterior22 and dorsal14 to plantar16 and divides the foot into medial and lateral halves. The transverse plane24 extends anterior20 toposterior22 and medial to lateral parallel to the floor26.

FIGS. 2-4 illustrate themetatarsus30 andproximal phalanx50 of the second MTP joint of the right foot. The medial andlateral epicondyles32,34, located on the medial-dorsal and lateral-dorsal aspects of themetatarsus30 respectively, are the origins of the medial and lateral proper collateral ligaments (PCLs)36,38 and the medial and lateral accessory collateral ligaments (ACLs)40,42 of the MTP joint. The medial PCL inserts at the medial-plantar aspect52 and the lateral PCL inserts at the lateral-plantar aspect54 of theproximal phalanx50. The medial and lateral ACLs fan out and insert into the medial and lateral borders of theplantar plate44 respectively. The metatarsus includes ametatarsal head46 having anarticular surface48 and the proximal phalanx includes aphalangeal head56 having anarticular surface58. Themetatarsus30 further includes alongitudinal axis60 extending lengthwise down the center of the bone.

The terms “suture” and “suture strand” are used herein to mean any strand or flexible member, natural or synthetic, able to be passed through material and useful in a surgical procedure including without limiting the above filaments, fabric, tendon, ligament, and fascia. The term “graft” is similarly defined as any member, natural or synthetic, that is used to reconstruct a soft tissue and includes sutures. The term “transverse” is used herein to mean crossing as in non-parallel. The term “bight” is used herein to mean a bend or loop formed in the intermediate portion of a suture.

FIGS. 5-13 illustrate anexemplary guide2300 for guiding a cutter to cut a bone. In this illustrative example, theguide2300 is configured as a drill guide to guide a drill, punch, pin, broach or the like to form holes in the bones adjacent the second MTP joint of the right human foot. Thedrill guide2300 includes a pair of plate-like members2302,2304 joined at ahinge2306 allowing a single degree of freedom such that the members may be pivoted between a first position and a second position. The members include a plurality of fixation holes for receiving fixation devices, e.g. fixation pins or screws, to secure the members to underlying bones and guide holes to guide the formation of tunnels in the underlying bones to facilitate soft tissue repair, replacement, and/or augmentation around the joint. Thefirst member2302 is configured to overlie the metatarsus and thesecond member2304 is configured to overly the phalanx.

Thefirst member2302 includes a planartop surface2309, afirst end2308 havingfixation holes2310, and ametatarsal guide portion2312. Themetatarsal guide portion2312 has a feature for guiding a cutter. In the illustrative example ofFIGS. 5-13, themetatarsal guide portion2312 includes medial and lateral spaced apart, hollow,tubular extensions2314,2315 each projecting upwardly and outwardly from thetop surface2309 and configured as a drill guide able to guide a drill, punch, broach, pin or the like. Thetubular extensions2314,2315 are oriented so that theiraxes2311,2313 intersect below themetatarsal guide portion2312. A mountingyoke2320 having opposed spaced apart arms extends from thefirst end2308 to asecond end2322 defining a pair ofeyelets2324 which straddle ablock2326 mounted on thesecond member2304. Theblock2326 has ahole2328 aligned with theeyelets2324. Abolt2330 andnut2325 join theeyelets2324 andblock2326. Alocking cam2332 is pinned to thehead2334 of thebolt2330 for relative rotation about apin2336 and includes alever2337 extending from the cam for rotating thecam2332 between a locked and unlocked position. Thebolt2330 and lockingcam2332 are operable to press theeyelets2324 together against theblock2326 to frictionally lock themembers2302,2304 in relative angular relationship.

Thesecond member2304 includes anelongated handle2340 having alongitudinal axis2341, a planartop surface2343,fixation holes2338 and aphalangeal guide portion2344. Thephalangeal guide portion2344 has a feature for guiding a cutter. In the illustrative example ofFIGS. 5-13, thephalangeal guide portion2344 includes medial and lateral spaced apart, hollow,tubular extensions2346,2347 each projecting upwardly and configured as a drill guide able to guide a drill, punch, broach, pin or the like alongaxes2345,2349. Thephalangeal guide portion2344 includes a pair ofgrooves2348 for receiving theyoke2320 of the first member to increase the relative positional accuracy and stability of the members relative to one another when the members are locked in the second coaxial position. Thesecond member2304 further includes ahead referencing member2350 having areference surface2351 for engaging an anatomic landmark. In the illustrative example ofFIGS. 5-13, thehead referencing member2350 has a concave spherical surface able to engage the articular surface of the metatarsal head. Opposite the concave surface is a convex back surface able to engage the articular surface of the phalangeal head. The second member further includes a pair of oppositely, laterally extendingbosses2342 for receiving a band to secure theguide2300 to the phalanx.

FIG. 9 depicts theguide2300 locked in the first parallel position.FIG. 10 depicts theguide2300 with thecam2332 unlocked by rotatinglever2337 and thefirst member2302 rotated part-way toward the second position.FIG. 11 depicts theguide2300 with thefirst member2302 rotated further toward the second position.FIG. 12 depicts theguide2300 with the first member rotated fully into the second position.FIG. 13 depicts theguide2300 with thecam2332 locked to fix the first andsecond members2302,2304 in the second position.

The relative position and orientation of thereference surface2351 of thehead referencing member2350, thehandle axis2341, thehandle top surface2343, thephalangeal extensions2346,2347, and themetatarsal extensions2314,2315 are determined from averaged anthropometric data relating the metatarsal head articular surface, metatarsal longitudinal axis, and transverse plane of the human body to the medial and lateral PCL origins and insertions when theguide2300 is locked in the second position and placed on the bone with thereference surface2350 engaged with the metatarsal head2106, thehandle axis2341 parallel to the axis110 of the metatarsus, and thehandle top surface2343 parallel to the transverse plane such that the metatarsal extension axes2311,2313 intersect the PCL origins and the phalangeal extension axes2345,2349 intersect the PCL origins.

FIGS. 14 and 15 illustrate anelongated tube2400 that may be used withguide2300 to protect soft tissue, facilitate engaging a cutter with the guide, and stabilize the cutter. For example, a long narrow drill, punch, pin, broach, or the like may be difficult to align with theextensions2314,2315,2346,2347 and/or may be so flexible that it tends to skive off the bone surface. Thetube2400 includes atubular shaft2402 having aproximal end2404, adistal end2406, and alongitudinal axis2408 extending from theproximal end2404 to thedistal end2406. The proximal end is radially enlarged to form aknob2410. Theknob2410 includes acounter sink2412 forming a funnel-like lead-in to theinner bore2414 of thetubular shaft2402. The outside of theshaft2402 is sized to slide into the extensions of theguide2300 and extend through theguide2300 to contact the underlying bone. Theshaft2402 provides positive guidance of the cutter to the bone surface. Theknob2410 provides the user with a gripping surface spaced away from theinner bore2414 to protect the user from being pricked by the cutter as the cutter is engaged with theinner bore2414. Thecountersink2412 guides the cutter into theinner bore2414.

FIGS. 16-25 illustrate theguide2300 in use to guide a cutter to form holes in the bones of the second MTP joint to facilitate, e.g., the reconstruction of the joint. Theguide2300 is brought near the joint with the first and second members folded in the first position as shown inFIG. 16. Thehead referencing member2350 is inserted into the joint space between themetatarsus2100 andphalanx2200 as shown inFIG. 17. Theconcave reference surface2351 is registered with the convexarticular surface2108 of the metatarsal head and the convex reference surface opposite the concave reference surface is registered with the concave articular surface of the proximal phalanx. Theguide handle axis2341 is oriented parallel to the axis110 of the metatarsus and the guide handletop surface2343 is oriented parallel to the transverse plane as shown inFIGS. 18 and 19. The first member is then pivoted into the second position as shown inFIGS. 20 and 21. The orientation of theguide2300 may be checked again. The cam is actuated to lock the members relative to one another and fixation devices, e.g. pins2360, may be placed in the guide fixation holes to fix the members to the bones as shown inFIGS. 22 and 23. Anelastic band2362 may be wrapped around the phalanx and engaged with thebosses2342 to secure thesecond member2304 to the phalanx in addition to, or as an alternative to, the fixation pins2360.

Once the members are aligned and secured, the guide is used to guide a cutter to form one or more tunnels in the bones as shown inFIGS. 24 and 25. Thecutter2364 may be engaged directly with an extension of a guide portion and advanced into the bone. Alternatively, anelongated tube2400 may first be engaged with the guide portion and extended to the bone surface. The cutter may then be engaged with theelongated tube2400 and advanced into the bone.

The illustrative guide ofFIGS. 5-13 includes two separate members hinged together. Alternatively, the guide may be provided as two separate guides each having a joint reference surface and useable independently to drill tunnels in the metatarsus and proximal phalanx. Alternatively, the hinge may be removed and the two members combined into one non-movableunitary structure2600 as shown inFIG. 26.

The illustrative guides ofFIGS. 5 and 26 are configured to reference to the anatomy of the right second MTP joint of the human foot to guide a cutter to form tunnels in the metatarsus and phalanx that intersect the medial and lateral PCL origins and insertions to facilitate routing and attaching ligaments to reconstruct the PCLs. The guide may be mirrored for use on the left foot and the guide may be provided in sizes for different MTP joints and various sized feet. However, it has been found that the variation of the PCL origin and insertion anatomy is surprisingly small for the second MTP joint across a wide range of foot sizes and it is possible to provide a single sized guide for all left second MTP joints and another for all right MTP joints for feet from at least a woman's US size 7 to a man's US size 11.

FIGS. 27-35 illustrate soft tissue reconstruction of the MTP joint of the human foot using tunnels formed with the guides ofFIG. 5 or26. For example, a PCL or ACL may be partially or fully torn due to acute trauma or chronic progressive failure. Likewise, these soft tissues may be intentionally released from their bony origins or attachments to facilitate a surgical procedure. The instruments and techniques of the present invention provide a way to reconstruct these soft tissues.

FIGS. 27-31 depict an illustrative method to reconstruct a PCL. In the illustrative example ofFIGS. 27-31, the medial PCL is reconstructed by placing a graft from the PCL origin on the distal aspect of the metatarsal to the PCL insertion on the proximal aspect of the proximal metatarsal.FIGS. 27-29 detail bone tunnels formed usingguide2300 or2600. For example, themetatarsal guide portion2312 has guided a cutter to form a medial-dorsal tunnel2500 extending from the medial PCL origin into the metatarsus and a lateral-dorsal tunnel2502 extending from the lateral PCL origin into the metatarsus. Thetubular extensions2314,2315 of themetatarsal guide portion2312 are oriented so that their axes intersect below the dorsal surface of the metatarsus. Thus, thetunnels2500,2502 intersect within the metatarsus and provide a path for fixing grafts to reconstruct one or both of the PCLs. Thephalangeal guide portion2344 has guided a cutter to form atunnel2510 extending from the medial-dorsal surface2512 of the phalanx to theinsertion2514 of the lateral PCL on the lateral-plantar surface of the phalanx. Theholes2560 are formed byfixation members2360 used to hold the guide in place.

FIG. 30 depicts agraft2504 with aproximal suture2506 stitched to its proximal end and adistal suture2508 stitched to its distal end. Theproximal suture2506 is threaded through the metatarsal bone tunnels by inserting it into the medial-dorsal tunnel2500 and retrieving it from the lateral-dorsal tunnel2502. Thedistal suture2508 is threaded through thephalangeal bone tunnel2510 by passing it from plantar to dorsal through the tunnel.

InFIG. 31 thesutures2506,2508 have been tensioned to pull the ends of thegraft2504 into the tunnels. The suture may be secured by any suitable method such as tying, securing over a button, securing with an interference fastener, or other suitable method. Similarly, thegraft2504 may be secured directly such as by interference fastener, pinning, or other suitable method.

FIGS. 32 and 33 depict an illustrative method to reconstruct a PCL. In the illustrative example ofFIGS. 32 and 33, a bilateral reconstruction is shown in which both the medial and lateral PCLs are reconstructed. For example, themetatarsal guide portion2312 ofguide2300 has guided a cutter to form a medial-dorsal tunnel2500 extending from the medial PCL origin into the metatarsus and a lateral-dorsal tunnel2502 extending from the lateral PCL origin into the metatarsus. Thetubular extensions2314,2315 of themetatarsal guide portion2312 are oriented so that their axes intersect below the dorsal surface of the metatarsus. Thus, thetunnels2500,2502 intersect within the metatarsus and provide a path for fixing grafts to reconstruct one or both of the PCLs. Thephalangeal guide portion2344 has guided a cutter to form atunnel2510 extending from the medial-dorsal surface2512 of the phalanx to theinsertion2514 of the lateral PCL on the lateral-plantar surface of the phalanx. The guide has also guided a cutter to form atunnel2520 extending from the lateral-dorsal surface2522 of the phalanx to the insertion of the medial PCL on the medial-plantar surface of the phalanx. These two phalangeal tunnels cross each other without intersecting. Agraft2524 with amedial suture2526 stitched to one end and alateral suture2528 stitched to another end. One of thesutures2526,2528 is threaded through the metatarsal bone tunnels and tensioned to pull thegraft2524 into the metatarsal bone tunnels. Themedial suture2526 is threaded through thephalangeal tunnel2520 intersecting the medial PCL insertion by inserting it into the medial-plantar opening of thetunnel2520 and retrieving it through the lateral-dorsal opening of thetunnel2520. Thelateral suture2528 is threaded through thephalangeal tunnel2510 intersecting the lateral PCL insertion by inserting it into the lateral-plantar opening of thetunnel2510 and retrieving it through the medial-dorsal opening of thetunnel2510.

InFIG. 33 thesutures2526,2528 have been tensioned to pull the graft ends into the phalangeal tunnels. The sutures may be secured by any suitable method such as tying, securing over a button, securing with an interference fastener, or other suitable method. Similarly, the graft may be secured directly such as by interference fastener, pinning, or other suitable method. In the illustrative example ofFIGS. 32 and 33, the sutures have been secured by tying them together over the bone bridge between thetunnels2510,2520.

The medial and lateral ACLs of the MTP joint have origins that are coincident with the PCLs and insert into the junction between the edges of theplantar plate44 and the intermetatarsal ligament (IML)2700 at the medial and lateral borders of the plantar plate. The IML is a narrow band of connective tissue that extends between and connects together the heads of the metatarsal bones. The same tunnels used to reconstruct the PCLs may be used to reconstruct the ACLs such that theillustrative guides2300,2600 configured for PCL reconstruction may also be used for ACL reconstruction.FIGS. 34 and 35 depict an illustrative method to perform a bilateral ACL reconstruction. The method begins as in the bilateral PCL reconstruction with the formation ofbone tunnels2500,2502 in the metatarsus andbone tunnels2510,2520 in the proximal phalanx. Agraft2702 is pulled through the metatarsal tunnels. The ends of thegraft2702 are passed through theIML2700 at the anatomic insertion of the ACL and then into thephalangeal tunnels2510,2520 and secured. In the illustrative example ofFIGS. 34 and35 the graft is secured by tying sutures connected to the graft ends together over the bone bridge between thetunnels2510,2520. One or both ACLs may be reconstructed along with one or both PCLs. For example, aPCL graft2504 may be attached as described relative toFIGS. 27-33 along with theACL graft2702.

Theguides2300,2600 may have any number of cutter guides targeted at any desired anatomical feature. While the illustrative examples have depicted a guide configured for ACL and PCL reconstruction of the right human MTP joint, the guide may be similarly configured to target other ligament reconstructions or other surgical procedures at other locations throughout the body.

FIGS. 36-39 depict an illustrative example of aguide2800 for guiding a cutter to cut a bone. In this illustrative example, theguide2800 is configured as a drill guide to guide a drill, punch, pin, broach or the like to form holes in the bones adjacent the second MTP joint of the right human foot. The guide includes abase member2802. In the illustrative example ofFIGS. 36-39, thebase member2802 is an arcuate member extending from afirst end2804 to asecond end2806. Anindexing member2808 and agrip2810 are attached to thebase member2802 near thefirst end2804. Aguide member2812 having a feature for guiding a tunnel forming implement is attached to thebase member2802 near the second end.

In the illustrative example ofFIGS. 36-39, theindexing member2808 andgrip2810 are coaxial relative to a firstlongitudinal indexing axis2814. Theindexing member2808 is in the form of a sharply pointed four sided pyramid projecting inwardly on the concave side of thearcuate base member2802. Thegrip2810 includes ariser post2816 extending upwardly from the convex side of thebase member2802 and is topped with acylindrical thumb pad2818 having aknurled perimeter2820, an upwardly directed face having acentral depression2822 for receiving a user's thumb, and an alignment feature such for example analignment mark2824 inscribed on the face. Theillustrative guide member2812 is a tube having an interior bore for guiding a tunnel forming implement and defining abore axis2826. Theindexing axis2814 and boreaxis2826 form an angle between them of approximately 73 degrees and converge on the convex side of the base member. Theindexing axis2814, boreaxis2826, andalignment mark2814 are oriented relative to one another based on averaged anthropometric data relating the dorsal surface of the metatarsus, the metatarsal longitudinal axis, and the metatarsal epicondyles.

As shown inFIGS. 41 and 40, with the indexing member engaged with the dorsal cortex of the metatarsal bone, the indexing axis perpendicular to the metatarsal axis, the alignment mark parallel to the metatarsal axis, and the bore axis directed toward the medial epicondyle, thebore axis2814 will project through the metatarsal bone and intersect the medial andlateral epicondyles32,34. These references may be adjusted so that thebore axis2814 projects slightly dorsal of the medial epicondyle and slightly plantar of the lateral epicondyle in order to provide additional clearance above the metatarsal bone medially for insertion of a cutter such as a drill. When abone tunnel2828 is formed along the bore axis, the tunnel exits will approximate the origins of the medial and lateral PCLs and ACLs at theepicondyles32,34.FIG. 41 illustrates the lateral opening of atunnel2828 formed using theguide2800.

FIG. 42 illustrates reconstruction of the PCL and ACL similar to that ofFIGS. 27-35 but utilizing a tunnel through the metatarsal epicondyles formed using theguide2800. For a unilateral repair, the tunnel may go part way or all the way through the metatarsal bone and the graft may be secured using techniques such as tying, using interference devices, or other suitable methods. Thetunnel2828 may be used for PCL reconstruction, ACL reconstruction, and combined PCL and ACL reconstruction with thegrafts2504,2704 routed as described relative toFIGS. 27-35.

FIG. 43 illustrates aguide2900 similar to theguide2800 ofFIG. 36 but having asecond guide member2910 offset further plantar than afirst guide member2812. Theguide member2910 is oriented to produce a bone tunnel plantar to thebone tunnel2828 and useable to provide a tunnel for ACL reconstruction distinct from the tunnel for PCL reconstruction. The lower tunnel may be useful where, for example, the PCL's are intact and it is desirable to provide a tunnel for ACL reconstruction that does not compromise the PCL origins. It may also be used, for example, to provide separate tunnels for PCL and ACL reconstruction. The more plantarsecond guide member2910 may be provided alone on a guide with the more dorsalfirst guide member2812 omitted or they may both be placed on the same guide as shown.

FIG. 44 illustrates two medial tolateral tunnels2828,2912 formed using theguide2900 ofFIG. 43 and separate reconstructions of the lateral PCL and lateral ACL withgrafts2504,2702. The reconstructions shown inFIGS. 42 and 44 are hybrid constructs providing a combined PCL & ACL functional replacement utilizing a tunnel on the proximal phalanx for the attachment of both grafts.

FIG. 45 illustrates an anatomic reconstruction of the PCL and an anatomic reconstruction of the ACL. The intact ACL is a fan shaped ligament that originates at the epicondyle on the metatarsal head and inserts into the border of the plantar plate. The medial ACL inserts into the medial border of the plantar plate and the lateral ACL inserts into the lateral border of the plantar plate. In the illustrative reconstruction ofFIG. 45, thetunnel2912 is located approximately at the origin of the ACL and agraft2702 is passed from thetunnel2912, under theintermetatarsal ligament2700, and back to thetunnel2912 where both ends of thegraft2702 are fixed to form a triangular graft construct similar to the intact ACL anatomy. In a bilateral ACL reconstruction, separate medial and lateral grafts may be passed and fixed in thetunnel2912 or a single graft may be passed through the tunnel and on each side of the metatarsal head with ends brought back to thetunnel2912 and fixed. The graft2701 may pass around any portion of theintermetatarsal ligament2700. For example, it may pass completely around the intermetatarsal ligament such that the portion includes the entire intermetatarsal ligament or it may pass through the metatarsal ligament and around a portion less than the entire ligament. The graft may pass through or around a portion of the plantar plate alone or in combination with the intermetatarsal ligament.

The surgical procedures and reconstructions relating to the MTP joint and surrounding bones may also be performed on corresponding joints and bones of the hand and such use is within the scope of the invention.

Claims (35)

What is claimed is:

1. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone, comprising:

forming a medial-dorsal tunnel extending from a medial-dorsal aspect of the metatarsus near the metatarsal head into the metatarsus; and

forming a lateral-dorsal tunnel extending from a lateral-dorsal aspect of the metatarsus near the metatarsal head into the metatarsus such that the medial-dorsal tunnel and lateral-dorsal tunnel intersect within the metatarsus;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels; and

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

2. The method ofclaim 1 wherein placing a graft between the bone tunnels comprises:

passing a suture attached to the graft through the metapodial bone tunnel.

3. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone, comprising:

forming a first bone tunnel with a first opening near the medial epicondyle of the metapodial bone and a second opening near the lateral epicondyle of the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels; and

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

4. The method ofclaim 3 wherein forming the first bone tunnel comprises:

engaging an indexing member of a tunnel guide with the dorsal surface of the metapodial bone;

aligning an alignment feature parallel to the metapodial bone axis; and

directing a guide member axis on a line from a medial to a lateral epicondyle of the metapodial bone.

5. The method ofclaim 3 further comprising forming a second bone tunnel extending from the medial side of the metapodial bone to the lateral side of the metapodial bone and plantar to the first bone tunnel.

6. The method ofclaim 5 wherein forming the second bone tunnel comprises:

engaging an indexing member of a tunnel guide with the dorsal surface of the metapodial bone;

aligning an alignment feature parallel to the metapodial bone axis; and

directing a guide member axis on a line parallel and plantar to a line from a medial to a lateral epicondyle of the metapodial bone.

7. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx, comprising:

forming a dorsal-plantar bone tunnel through the proximal phalanx near the joint;

placing a graft between the metapodial and phalangeal bone tunnels; and

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

8. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels;

securing the graft; and

wherein forming the bone tunnels comprises:

positioning a drill guide adjacent the joint;

engaging a reference portion of the drill guide with an anatomic landmark;

aligning a guiding portion of the drill guide in alignment with an anatomic attachment of a ligament on the metapodial bone; and

guiding a cutter with the first guiding portion to form the metapodial bone tunnel.

9. The method ofclaim 8 wherein the reference portion is oriented relative to the guiding portion based on human anatomy relating anatomic landmarks associated with the kinematic operation of the bone joint to the ligament anatomic attachments.

10. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels;

securing the graft; and

wherein forming the bone tunnels comprises:

positioning a drill guide adjacent the joint;

engaging a reference portion of the drill guide with an anatomic landmark;

aligning a guiding portion of the drill guide in alignment with an anatomic attachment of the ligament on the proximal phalanx; and

guiding a cutter with the second guiding portion to form the phalangeal tunnel.

11. The method ofclaim 10 wherein the reference portion is oriented relative to the guiding portion based on human anatomy relating anatomic landmarks associated with the kinematic operation of the bone joint to the ligament anatomic attachments.

12. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone, comprising:

positioning a drill guide adjacent the joint;

engaging a first reference portion of the drill guide with a first anatomic landmark;

aligning a first guiding portion of the drill guide in alignment with a medial-dorsal aspect of the metapodial bone;

aligning a second guiding portion of the drill guide in alignment with a lateral-dorsal aspect of the metapodial bone;

guiding a cutter with the first guiding portion to form a first tunnel into the metapodial bone; and

guiding a cutter with the second guiding portion to form a second tunnel into the metapodial bone intersecting the first tunnel;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels; and

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

13. The method ofclaim 12 wherein engaging a reference portion with a first anatomic landmark comprises engaging a surface of the reference portion with an articular surface of the metapodial phalangeal joint.

14. The method ofclaim 13 wherein the surface is a concave surface and it is engaged with the head of the metapodial bone.

15. The method ofclaim 13 wherein the surface is a convex surface and it is engaged with the head of the proximal phalanx bone.

16. The method ofclaim 12 wherein the guide further comprises an alignment axis, the method further comprising:

aligning the alignment axis parallel to the longitudinal axis of the metapodial bone.

17. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx, comprising:

positioning a drill guide adjacent the joint;

engaging a first reference portion of the drill guide with a first anatomic landmark;

aligning a guiding portion of the drill guide in alignment with the proximal phalanx; and

guiding a cutter with the guiding portion to form the phalangeal tunnel;

placing a graft between the metapodial and phalangeal bone tunnels; and

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

18. The method ofclaim 17 wherein engaging a reference portion with a first anatomic landmark comprises engaging a surface of the reference portion with an articular surface of the metapodial phalangeal joint.

19. The method ofclaim 18 wherein the surface is a concave surface and it is engaged with the head of the metapodial bone.

20. The method ofclaim 18 wherein the surface is a convex surface and it is engaged with the head of the proximal phalanx bone.

21. The method ofclaim 17 wherein the guide further comprises an alignment axis, the method further comprising:

aligning the alignment axis parallel to the longitudinal axis of the metapodial bone.

22. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels;

securing the graft; and

wherein the metapodial bone tunnel intersects the anatomic attachment of an accessory collateral ligament on the metatarsus, the method further comprising:

passing the graft through the transverse metatarsal ligament.

23. A method of reconstructing soft tissue of a metapodial phalangeal joint of a human extremity, the joint including a metapodial bone and a proximal phalanx, the extremity having volar and dorsal aspects, the method comprising:

forming a metapodial bone tunnel in the metapodial bone;

forming a phalangeal bone tunnel in the proximal phalanx;

placing a graft between the metapodial and phalangeal bone tunnels;

securing the graft; and

wherein placing a graft between the metapodial and phalangeal bones includes passing the graft around a portion of an intermetapodial ligament.

24. The method ofclaim 23 wherein the metapodial bone tunnel intersects the anatomic attachment of a proper collateral ligament on a metatarsus and the phalangeal bone tunnel intersects the anatomic attachment of the proper collateral ligament on the proximal phalanx.

25. A method of reconstructing a proper collateral ligament adjacent a metatarsophalangeal joint of a human foot, the method comprising:

positioning a drill guide adjacent the joint;

aligning a first guiding portion of the drill guide in alignment with the anatomic attachment of a proper collateral ligament on the metatarsus;

aligning a second guiding portion of the drill guide in alignment with a portion of the metatarsus;

aligning a third guiding portion of the drill guide in alignment with the anatomic attachment of the proper collateral ligament on the proximal phalanx;

guiding a cutter with the first guiding portion to form a first tunnel into the metatarsus;

guiding a cutter with the second guiding portion to form a second tunnel into the metatarsus intersecting the first tunnel;

guiding a cutter with the third guiding portion to form the phalangeal tunnel;

placing a first portion of a first graft at least partially into the first tunnel;

placing a second portion of the first graft at least partially into the phalangeal tunnel; and

securing the first graft.

26. The method ofclaim 25 wherein placing the first and second portions of the graft comprise:

placing a first suture through the first and second tunnels;

tensioning the suture to pull the first portion of the first graft at least partially into the first tunnel;

placing a second suture through the phalangeal tunnel; and

tensioning the second suture to pull the second portion of the first graft at least partially into the phalangeal tunnel.

27. The method ofclaim 25 further comprising:

placing a portion of a second graft in the first tunnel;

passing the second graft around a portion of the intermetatarsal ligament;

placing a second portion of a second graft in the phalangeal tunnel; and

securing the second graft.

28. A method of reconstructing medial and lateral proper collateral ligaments adjacent a metatarsophalangeal joint of a human foot, the method comprising:

positioning a drill guide adjacent the joint;

aligning a first guiding portion of the drill guide in alignment with the anatomic attachment of a medial proper collateral ligament on the metatarsus;

aligning a second guiding portion of the drill guide in alignment with the anatomic attachment of a lateral proper collateral ligament on the metatarsus;

aligning a third guiding portion of the drill guide in alignment with the anatomic attachment of a medial proper collateral ligament on the proximal phalanx;

aligning a fourth guiding portion of the drill guide in alignment with the anatomic attachment of a lateral proper collateral ligament on the proximal phalanx;

guiding a cutter with the first guiding portion to form a first tunnel into the metatarsus;

guiding a cutter with the second guiding portion to form a second tunnel into the metatarsus intersecting the first tunnel;

guiding a cutter with the third guiding portion to form a third tunnel in the proximal phalanx;

guiding a cutter with the fourth guiding portion to form a fourth tunnel in the proximal phalanx;

placing a graft through the first and second tunnels with a first graft portion extending out of the first tunnel on the medial side of the metatarsus and a second graft portion extending out of the second tunnel on the lateral side of the metatarsus;

placing the first extending portion of the graft at least partially into the third tunnel;

placing the second extending portion of the graft at least partially into the fourth tunnel; and

securing the graft.

29. A method of reconstructing an accessory collateral ligament adjacent a metatarsophalangeal joint of a human foot, the method comprising:

positioning a drill guide adjacent the joint;

aligning a first guiding portion of the drill guide in alignment with the anatomic attachment of an accessory collateral ligament on the metatarsus;

aligning a second guiding portion of the drill guide in alignment with the proximal phalanx;

guiding a cutter with the first guiding portion to form a tunnel in the metatarsus;

guiding a cutter with the second guiding portion to form a tunnel in the proximal phalanx;

placing graft material at least partially into the first tunnel;

placing graft material at least partially into the phalangeal tunnel; and

securing the graft material in the tunnels.

30. The method ofclaim 29 further comprising:

passing the graft material around a portion of an intermetatarsal ligament.

31. The method ofclaim 30 wherein the graft material on the medial and lateral sides of the joint comprises a continuous piece of graft material.

32. The method ofclaim 29 further comprising:

placing graft material on the medial side of the metatarsophalangeal joint to reconstruct a medial accessory collateral ligament; and

placing graft material on the lateral side of the metatarsophalangeal joint to reconstruct a lateral accessory collateral ligament.

33. A method of reconstructing an accessory collateral ligament adjacent a metatarsophalangeal joint of a human foot, the method comprising:

positioning a drill guide adjacent the joint;

aligning a guiding portion of the drill guide in alignment with the anatomic attachment of an accessory collateral ligament on the metatarsus;

guiding a cutter with the guiding portion to form a tunnel in the metatarsus;

placing graft material such that it passes from the tunnel around a portion of the intermetatarsal ligament and back to the tunnel; and

securing the graft material relative to the tunnel.

34. The method ofclaim 33 wherein passing graft material comprises passing graft material on the medial side of the metatarsus and around a portion of the intermetatarsal ligament adjacent the medial border of the plantar plate and passing graft material on the lateral side of the metatarsus and around a portion of the intermetatarsal ligament adjacent the lateral border of the plantar plate.

35. The method ofclaim 34 wherein the graft material on the medial and lateral sides of the joint comprises a continuous piece of graft material.

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